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Medical
Professionalism — Focusing on the Real Issues The New England Journal of Medicine
David J. Rothman, Ph.D.
April
27, 2000, Number 17 There is considerable interest in reinvigorating medical professionalism. This interest reflects a profound unease with the seeming primacy of economic factors among those currently affecting medical practice in the United States. There is general agreement that patients' interests must take precedence over physicians' financial self-interest and that professionalism also entails service to vulnerable populations and civic engagement. But as commentators focus on managed care and other issues of the moment, many considerations are entirely overlooked. These omissions may well subvert the effort to make professionalism relevant to contemporary medicine. Because the focus on the threats from managed care is so intense, the thorny question of whether professionalism is more or less vibrant or effective today than it was under fee-for-service medicine has been slighted. Commentators do not consider whether professionalism has to be revived or, more dauntingly, created. Why is there such steadfast inattention to the past? Perhaps the reason is that an analysis of the historical record would severely complicate the agenda, forcing a shift of attention from managed care to the more fundamental problem of professionalism in American medicine. Take the question of how well physicians met the demands of professionalism during the period from 1910 to 1980. Did they put their patients' interests first? That some physicians did is clear, but given the compelling evidence of overtreatment of patients and such practices as self-referral and fee splitting, it would be difficult to conclude that before managed care was introduced the profession as a whole unequivocally gave precedence to the interests of patients. At least since the inception of Medicare, which led to the extraordinary rise in physicians' incomes, some (perhaps many) physicians acted in ways that were designed to enhance their financial positions. Thus, to the degree that managed care does not pose the initial or exclusive challenge to the precept of putting the interests of patients first, it is necessary to examine the internal, not the external, factors that have weakened professionalism. The problem involves medical norms and practices more than reimbursement formulas under managed care. The most pressing question is not how to redraft contracts between physicians and health maintenance organizations (HMOs) but how to reduce physicians' financial interests and better monitor their behavior. Concepts of professionalism are particularly relevant to this task, as a charge to physicians to make their financial compensation secondary to the welfare of their patients. In fact, professionalism may well require some financial sacrifices. Discussions about professionalism before the introduction of managed care involved other issues, such as technical expertise and self-regulation of medical practice. These considerations, as formulated by Talcott Parsons in the 1920s and 1930s, were once understood as the foundation of professionalism. In fact, the goal of maintaining technical expertise among physicians has been exceptionally well met. Board certification has proved so effective a mechanism that problems involving technical expertise have almost disappeared from discussions of professionalism. However, the record on self-regulation, particularly with respect to incompetence and impairment, is replete with failures. Professional societies, with only a few exceptions, have not effectively disciplined their members. By-laws may provide for reprimand, probation, suspension, and expulsion of errant physicians. But most organizations do not publish records of their disciplinary actions. By all accounts, complaints against members are few and rarely result in disciplinary action. The inadequacies of self-regulation make it clear that an examination of professionalism must go beyond questions of money and managed care. To the extent that self-regulation is the focus, professionalism today has to be invented, not restored. This proposition is even more true of the current effort to make civic and social obligations central to medical professionalism. Over the past century, physicians have been extraordinarily reluctant to enter the public arena. A few exceptions aside, most physicians have not taken part in national politics (even when health care reform was debated), let alone in state or local politics (e.g., serving on school boards). If the historical record of civic engagement is so bleak, how can it be changed? Why expect doctors to engage in public service now if they have rarely done so in the past? Just as the recent literature on professionalism ignores history, it slights the structural barriers, apart from managed care, to the accomplishment of the principles of professionalism. Most of the authors, for example, pay little attention to the interactions between pharmaceutical companies and physicians or the influence of such companies on undergraduate medical education and residency training. Despite the evidence that this influence is far-reaching, the few analysts who do remark on the issue fail to convey its importance. Pellegrino and Relman, for example, assert that contributions from pharmaceutical companies should not dominate the budgets of professional associations. But they do not cite the data showing how extensive these contributions are or discuss what the associations might have to do to survive without them. To select one example from an organization that specifies in its budget reports the contributions of pharmaceutical companies, all 21 major donors to the American Academy of Family Physicians in 1995 were drug companies. If more professional societies divulged information about such contributions, this example might be multiplied many times over. There is also substantial evidence that gifts from pharmaceutical companies (such as subsidies for meetings and travel) influence the prescribing practices and formulary choices of physicians. A discussion of threats to professionalism that does not address the influence of pharmaceutical companies omits a critical consideration, one that, unlike managed care, is largely subject to the control of physicians. Perhaps the most important omission from the recent discussions of professionalism is the question of how to implement and enforce professional standards. There are calls to expand the teaching of professionalism in medical schools and in residency programs and to have professional societies become more explicit about the norms they espouse. But the limitations of these two approaches are apparent. Ludmerer observes that lectures in the preclinical curriculum are no match for the rough-and-tumble lessons of clinical training. The rhetoric on respect for patients is too easily undercut by the reality of exhausted residents teaching medical students how to avoid a "hit." But Ludmerer does not suggest how to implement a change. He is eager "to make the internal culture of academic medical health centers less commercial and more service oriented," but he has no more specific strategy for accomplishing this goal than to appeal to the "courage" of medical leaders. Nor is it completely satisfactory to depend on a public declaration of norms, whether through new oaths or ceremonies in which first-year medical students are given white coats. Take, for example, the call for greater social engagement through the provision of care to underserved populations or greater civic participation. Professional resolutions favoring such practices might have some effect on individual behavior, but it is doubtful that they would have a substantial collective impact. Lofty phrases generally do not change customary ways of doing things. To put it another way, the burden is surely on those who would rely on such strategies to demonstrate that they would be successful. In what other ways might professionalism be promoted and implemented? There are a range of possible strategies, many requiring fundamental departures from current procedures. First, professional and board-certifying societies could require rather than recommend standards of behavior, including service. One could imagine that, like continuing medical education, service to vulnerable groups of people would be required to maintain certification. A number of community organizations already attempt to meet the medical needs of uninsured patients by coaxing physicians, more or less successfully, to provide care to such patients without charging fees. A minimal requirement to render free care might improve the health of poor patients and promote medical practice that exemplifies the precepts of professionalism. The controversy that would greet such a proposal cannot be underestimated, especially since physicians are under pressure to see larger numbers of insured patients. But controversy may be the price that has to be paid for taking professionalism seriously. Second, professional associations could form alliances with consumer groups to accomplish goals that neither can realize separately. Sullivan suggests that medicine might wish to "go public" and become "much more of a partner to other fields and social interests." This approach informs at least one program, Medicare as a Profession (I chair the program's advisory board). Part of the Open Society Institute, it funds joint efforts by consumer groups and medical groups to improve the quality of care, implement professional standards, and provide care to underserved populations. Although physicians have traditionally refrained from joining forces with consumer groups, the need for such alliances may break the tradition. Third, the medical school and residency curriculum should be altered, not only by including lectures on professionalism but also by inculcating the skills necessary to promote it. To the degree that the profession accepts a commitment to social engagement, the curriculum should teach advocacy skills along with diagnostic skills. Once again, this would constitute a startling break with established patterns. Medical school faculty would have to include persons trained in advocacy and community organization. The clash of cultures would be great, but so would the benefits. Fourth, medicine in its organized capacity must encourage and protect whistle-blowers, so that the profession is not so dependent on outsiders to identify and publicize problems. Whether the problem is specific instances of conflict of interest or abuses by managed-care companies, journalists and government officials have taken the lead in uncovering abuses and providing remedies. Thus, when HMOs imposed restrictions on the length of hospital stays for new mothers and women recovering from mastectomy, the press — not organizations representing obstetricians or oncologists — spearheaded the protests and brought about corrective legislation. Journalists have been especially active in ferreting out instances of conflict of interest. To be sure, many medical journals have reported on the overall dimensions of the problem, and universities and medical schools have established useful oversight procedures. But it is the press that continues to highlight the failures of the existing system to control the behavior of physicians. A recent article in the New York Times on the development and testing of new cardiac devices is a telling case in point. Fifth, professional organizations must be persuaded to expand the agenda for which they lobby and advocate. Nearly all these organizations engage in extensive lobbying, with many spending over $500,000 annually on such activities. Through lobbying firms or their own staff, they attempt to influence legislation on various matters, including health insurance, drug regulation, managed care, antitrust violations, and liability reform. But in most, if not all, cases, these efforts conform to the special interests of the organization's members. Thus, the American Academy of Dermatology has fought to maintain direct access to specialists because it is the "most efficient and cost-effective method of providing quality dermatologic services."By the same token, the American Academy of Ophthalmology has strongly opposed the creation of "centers of excellence as they apply to cataract surgery," as well as "single surgery payment provisions," apparently because they would reduce earnings for ophthalmologists. And when Medicare benefits were being debated by Congress, the American College of Gastroenterology lobbied to include screening for colorectal cancer as a benefit. Imagine what could have happened if these societies had advocated for the well-being of patients without regard for their own special interests. Support by dermatologists and ophthalmologists for colorectal-cancer screening would carry great weight in the debate over whether to include it as a benefit. Again, the barriers to such activities are formidable. Members of professional organizations do not want their dues spent on advancing the other fellow's specialty, and they may believe that only subspecialists can determine what patients need. But think of how the public might respond to advocacy that was driven not by narrow self-interest but by a broader professional vision of patients' welfare. Sixth, professional societies, medical schools, and teaching hospitals should adopt policies to minimize the influence of pharmaceutical companies and their representatives. If professional societies raised annual membership dues and registration fees for meetings, they would reduce their dependence on underwriting and advertising by drug companies. At the very least, these organizations should refrain from such practices as identifying drug-company donors in programs for meetings according to the level of support (platinum, gold, silver, and so forth); this suggests a degree of venality that is inconsistent with professionalism. Societies may not wish to ban drug-company booths from annual meetings on the grounds that such a restriction might hamper the spread of new information, but no educational purpose is served by allowing the booths to dispense such "brand reminders" as pens, note pads, briefcases, flashlights, and golf balls. In the same spirit, medical schools should adopt formal rules that prohibit all gifts from drug companies to students, whether books, stethoscopes, or meals. Medical training should not include acquiring a sense of entitlement to the largesse of drug companies. Finally, teaching hospitals should enforce these same restrictions, proscribing drug-company sponsorship of lunches, conferences, and travel for house staff, and should also make it clear that accepting birthday presents, Christmas gifts, or food and drink off the premises from drug-company representatives violates the ethical norms of the profession. However fanciful, impractical, or misguided these suggestions may seem, they make it clear that physicians have avoided the admittedly tough question of how professionalism is to become more central to their thinking and behavior. A general call to embrace the ethic may be appealing and may even exert some influence in the long run, but it is not sufficient to bring about substantial change in the near future. Professionalism is too important for an exclusive reliance on such tactics. An infusion of strength and relevance is needed. By one means or another, professionalism must become a vital part of American medicine today.
References
Related Letters: Medical Professionalism —
Focusing on the Real Issues This article has been cited by other articles:
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